A skillful initial workup
for suspected cancer is an essential part of effective primary care
practice. Developing a logical and practical diagnostic approach
to the more common cancers (e.g., breast, skin, colon, lung, prostate)
is an excellent means of sharpening basic history-taking, physical
examination, and communication skills and learning how to use diagnostic
studies in a cost-effective manner. Encountering patients in whom
cancer is a diagnostic possibility will stimulate learning the important
clinical presentations and natural histories of these life-threatening
conditions. Focusing on cancer diagnosis helps to concentrate the
student’s learning and avoids premature immersion in the often
very technical and specialized issues of treatment.

Pre-requisites

Prior knowledge and skills
acquired during the pre-clerkship experience should include:

principal clinical
presentations, clinical courses, complications, and causes of
death for the most common cancers

basic methods of
initial evaluation, including the sensitivity and specificity
of basic diagnostic studies and indications for their use, including:

indications for
skin biopsy in a patient with a suspicious skin lesion

indications for
breast biopsy in a person with a breast nodule or abnormal
screening mammogram

indications for
a lymph node biopsy in a person with isolated lymphadenopathy

initial cost-effective
workups for:

isolated
pleural effusion

pulmonary
nodule

liver nodule

prostate
nodule

elevated
PSA

testicular
nodule

stool test
positive for occult blood

abnormal
PAP smear

testicular
nodule

other findings
suggestive of gastrointestinal and urogenital cancers

Skills

Students should demonstrate
specific skills, including:

History-Taking
Skills: Students should be able to obtain, document,
and present an age-appropriate medical history, that differentiates
among etiologies of disease including:

skin cancer

breast nodules
and secondary signs of breast cancer

lymphadenopathy

pulmonary nodule

prostate cancer

colon cancer

Physical Exam
Skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease, including
assessing for:

common skin cancers

breast nodules
and secondary signs of breast cancer

lymphadenopathy

pleural effusion

liver nodularity
and enlargement

prostatic nodule

testicular nodule

pelvic mass

cervical erosion

Students should be
able to cost-effectively design and carry out the initial diagnostic
and staging workup, which includes ordering and interpreting,
when appropriate:

skin biopsy

breast imaging
and biopsy

lymph node biopsy

chest CT and pleural
fluid analysis

upper and lower
GI imaging and endoscopy

abdominal CT and
ultrasound

prostate and testicular
ultrasounds and biopsy

alkaline phosphatase/acid
phosphatase/PSA

liver biopsy

bone scan

Pap smear

Differential
Diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical
exam findings to:

provide prompt
and critical review of the findings of the initial evaluation

establish a tentative
diagnosis and estimate severity and prognosis by use of staging
criteria

Laboratory
Interpretation: Students should be able to recommend
when to order diagnostic and laboratory tests and be able to interpret
them, both prior to and after initiating treatment, based on the
differential diagnosis including consideration for test cost and
performance characteristics, as well as patient preferences.

Laboratory and diagnostic
tests should be selected carefully to minimize the risks of
false-positive and false-negative results.

Communication
Skills: Students should be able to:

communicate the
working plans, diagnosis, treatment plan and prognosis of
the disease to patients and their families in a clear and
supportive manner for bearing bad news

provide a concise
oral and written presentation of clinical findings, assessment,
and initial diagnostic plan to faculty preceptor

Basic Procedural
Skills: Students should be able to perform:

cervical PAP
smear

stool occult
blood testing

Management
Skills: Students should develop an appropriate evaluation
and treatment plan for patients with cancer including:

provision of
support and information to patient, and coordination of care
for workup

timely arrangement
of pertinent consultations

accessing and
utilizing appropriate information systems and resources to
help delineate issues related to common cancers

Attitudes and
Professional Behaviors

Students appreciate
the importance of:

keeping the patient
well informed and well supported

maintaining close
collaboration and coordination with specialty consultants

maintaining responsibility
for coordinated care and support of the patient